The use of noninvasive blood pressure measurement measurements in critically ill patients is common despite the paucity of evidence validating its accuracy in critically ill patients. Given this widespread use, accuracy and precision validation studies comparing noninvasive blood pressure measurement with intra-arterial blood pressure measurement in critically ill patients should be performed.

Since its introduction over 9 years ago, capsule video endoscopy has become increasingly popular within the gastroenterology community, leading to its use in a growing number of patients including the elderly. With the widespread adoption of this diagnostic modality within the elderly population comes the added risk of capsule aspiration. We present such a case where a 90-year-old patient was admitted after accidental aspiration of a capsule. Removal of the capsule posed a therapeutic challenge. In the article, we discuss the novel use of a Roth Net expandable foreign body extractor to remove the capsule using a flexible bronchoscope with minimal need for sedation. As video capsule endoscopy is used more routinely in elderly patients and clinical pulmonologists will be more frequently called up to assist in foreign body removal, our experience highlights that it is possible to remove these large capsules with a flexible bronchoscope and avoid the need for rigid bronchoscopy in this high-risk patient group.

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Pulmonologists are routinely called to evaluate and care for patients with pulmonary hypertension. Traditionally there has been a reluctance to perform transbronchial lung biopsies in this group of patients. We carried out a literature review to evaluate the myth that bronchoscopy is contraindicated in patients with pulmonary hypertension.Myth: Flexible bronchoscopy with transbronchial lung biopsy is contraindicated in patients with pulmonary hypertension. (Clin Pulm Med 2009;16: 281-283) P ulmonary Hypertension (PHTN) has been divided by the World Health Organization into 5 categories based on the underlying etiology. 1 This classification is important because of different treatment options for patients with different etiologies, however, irrespective of the etiology, the end result is an elevation of pressure in the pulmonary vasculature. Ohmichi et al 2 noted that chronic venous PHTN caused visually identifiable dilation of bronchial veins on flexible bronchoscopy (FB). Since then it has been proposed that the increased perfusion pressure in the capillary bed of PHTN patients may hypothetically lead to excessive bleeding after transbronchial lung biopsy (TBLB). 3 It is perhaps for this reason that the British Thoracic Society in their 2001 guidelines 4 on diagnostic FB regard PHTN patients as being high risk for bleeding complications. However, they did not comment on the role if any of TBLB in this group of patients. Historically, opinions have varied on the role of TBLB in PHTN patients. Zavala 5 considered PHTN to be a relative contraindication to performing TBLB, while Cordasco et al 6 felt that TBLB could be safely performed in patients with PHTN.Wahidi et al 3 performed a survey of 158 pulmonologists in the United States and noted that 28.7% of physicians felt presence of PHTN to be an absolute contraindication to performing TBLB and 58.6% felt it was a relative contraindication.We performed a PUBMED search of the literature for original articles that addressed the issue of safety of TBLB in patients with PHTN.

Thrombocytopenia is an increasingly common finding in an expanding population of immunocompromised patients. Pulmonologists are frequently called upon to perform flexible bronchoscopy in this high risk group of patients. The low platelet count in these patients may predispose them to a high risk of bleeding complications with bronchoscopic procedures. We carried out a literature review to evaluate the myth that bronchoscopy is unsafe in thrombocytopenic patients. MYTHBronchoscopy including bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB) should not be performed in patients with below normal platelet counts due to the excessive risk of bleeding.Hemorrhage and hemorrhagic complication remain a concern in thrombocytopenic patients undergoing bronchoscopy. In this article, we review the available literature regarding the risk of bleeding in thrombocytopenic patients undergoing diagnostic bronchoscopy.Thrombocytopenia is an increasingly common finding in an expanding population of patients that are immunocompromised due to cytoreductive therapy and malignancy. Since pulmonary complications are a major cause of morbidity and mortality in this patient population, flexible bronchoscopy (FB) is often used to help to diagnose pulmonary disease. We are routinely concerned about potential complications of FB and are interested in reduction strategies. Many physicians have expressed concerns and cautions when performing FB with BAL and TBLB in thrombocytopenic patients. 1 We performed a literature search to evaluate the presence and quality of data regarding rates of complications and safety in thrombocytopenic patients undergoing FB. Important questions that guide platelet transfusion in thrombocytopenia include: at what platelet count should platelet transfusions be initiated and what dose should be given? 2 According to older studies, significant spontaneous bleeding does not occur until the platelet count is 5000 platelets/uL or less. 2 For a chronically thrombocytopenic patient, a platelet level of 10,000 has been recommended as a trigger for transfusion to prevent spontaneous hemorrhage. 3 However, studies of thrombocytopenic patients undergoing procedures is sparse. A consensus of medical opinion is that a platelet count of 50,000 should be maintained for those procedures that disrupt the vasculature. 2 Bronchoscopy with BAL alone will not usually disrupt the vasculature however TBLB frequently does. We searched the literature for original research related to bronchoscopy, thrombocytopenia, and safety.